Teacher

Rarely, Dr. is interested in doing emergency studies of vectorcardiogram. Therefore, there is lack of information and materials for the trainee except the group which has connection with Professor Alberto Benchimol. Further, most vectorcardiographic investigators are reluctant to mention who is their teacher. Indeed, as Dr. Edenbrandt clearly pointed out that " . . . Experienced vectorcardiographic interpreters are scarce." (J Electrocardiol 1995; 28: 169) Therefore, readers do not know whether the teacher can interpret emergency vectorcardiogram. It is to my own experience that the research funding is not easy to get due to lack of experienced board members within the committee to grant a research grant.

Researcher background and attitude

Owing to the lack of teachers and emergency teaching material), Dr. and Ph D would like to use summated X,Y,Z, orthogonal electrocardiogram to do the study. They can detour the detailed vectorcardiographic interpretation process and call the Frank orthogonal electrocardiogram wrongly as 'vectorcardiogram'. Further, Ph D researchers have been barred from the Emergency Service Coronary Care Unit, or Intensive Care Unit due to no medical qualifications. Therefore, most of the works are less interesting for the clinician. Do not feel surprised that the Cardiologists responsible for emergencies 'out of touch'. The Drs are either too busy in clinical work or struggling for research grants. Therefore, they do have time for 24 hours on call for the emergency study. They will ask technicians or electrocardiographers  for vectorcardiogram . This attitude absolutely betrays the orthodox attitude (Br Heart J 1987;58:552) of medical research. Indeed, this kind of investigator may have 1,000 published papers, but none of it produced by himself. Dr. Lawrence Peter will classify this as having 'pseudo-achievement syndrome'*. The variation of lead placement of the scalar electrocardiogram by technicians or electrocardiographers can seriously influence their results as shown in the literature. In fact, through my own observation while I was in the Oxford University, Professor Peter Sleight in the Cardiac Department was still putting arterial lines by himself for his hypertension studies. This proved to me what is the orthodox attitude of the medical research.

Reviewer background

Due to lack of teachers and emergency materials, my own experience is most reviewers do not know how to interpret emergency vectorcardiogram. They usually depend on technicians to supply them tracings. The pressure for quick and many publications in order to climb the ladder of medical hierarchy prevents them from going to the Coronary Care Unit, Intensive Care unit or Emergency Service to record tracings by their own hands. Therefore, mostly they only depend on literature and their own imagination to write down their comments.

False believing

The frequently cited old research (Am J Cardiol 19( 17: 829-878 ) that the vectorcardiogram is less useful  had numerous problems (e.g. a time lags between vectorcardiogram and other examinations like autopsies were unacceptably long). The same article will never published by the standard of the same journal today

Students in the medical school are taught to respond to their teachers in a reflex manner like in the ward round. However, smart students soon learned that if they questioned their teachers about what they have learned might influence the score he or she will get. This would have tremendous influence on his future as a 'professional processionary puppet'** in the medical field. Therefore, students just take his teacher's comments as truth.

Improper method to correlate with the vectorcardiogram

The old literature has always use coronary angiogram and ventriculogram as standard to correlate with the vectorcardiogram. Coronary anatomy imaged by "lumenography" and visually assessed is an imprecise standard for the development of myocardial ischaemia. Angiographic anatomy is only indirectly related to the ischaemic event, and no absolute percentage of the coronary artery stenosis will produce myocardial ischaemia had been established in the literature. Old studies classified stunned or hibernating myocardium, reversible ischaemia, or conduction disturbance as myocardial infarction while assessing wall motion abnormalities of ventriculogram. Further, ventriculogram lacks horizontal plane to compare with the vectorcardiogram. This is not so now due to the 3-dimensional vectorcardiogram had newly available 3-dimensional techniques like Single-Photon Emission computed Tomogram, Magnetic Resonance Imaging . . . etc. One has also proposed the unification of presentation with the vectorcardiogram in a book - Emergency Vectorcardiography.

Insurance organizations

Usually insurance organizations will follow the medical literature to form their policy. However, once they have formed the policy, it will influence Drs practicing medicine, especially in an insurance refund policy oriented medical system. Personally I agree with Dr. Nancy Dickey mentioned from the American Medical Association to the News that "If we don't do something to change the fiscal policy of Medicare . . . instead of turning to the insurance companies and saying 'we're sorry', we'll be turning to the elderly and saying 'we're sorry!" on 4th December, 1996.

Computer interpretation

Several groups in Europe and America are using digital recording and processing of the Frank X, Y, Z orthogonal electrocardiogram for clinical and research purposes. However, I wish to quote Professor Benchimol's comments about computer interpretation (Am J Cardiol 1975; 36: 76) that " ....Visual inspection of the P, QRS and T loops is still desirable for definitive interpretation of the vectorcardiogram in the individual case Superficial and completely qualitative examination of either the X,Y, Z, leads or vector loops is to be condemned and has been a pitfall. Careful attention should be directed to the magnitude, duration, rotation and orientation of the critical initial and maximal deflection vectors before diagnostic conclusions are reached. Such analysis permits maximal utilization of information contained in planar loop projections and precludes major individual interpretive variation, which has been documented in the past (Am J Cardiol 1966; 17: 829). Visual inspection or measurement and computer analysis are in no way mutually exclusive, and both techniques in combination are useful for clinical application and research purposes." Further, Lebowitz et al (Chest 1986 89: 78) found that hand measurements are more accurate, mostly because of angle and length determinations being affected by shifts in the loop; pattern recognition without computer appears to be more consistent as well.

Computer software and hardware

Three-dimensional vectorcardiography was developed too early without any comparable three-dimensional methods to understand its meaning. Previously, there were no powerful computers available. The time has finally come in favour of three-dimensional presentation of the cardiac electrical activity. This is because escalating speed in developing more powerful centre processing unit in the computer hardware. Further, powerful three-dimensional software is already available in the market with reasonable price, e.g.: 3D Studio Max, True Space, Electrical Image, Extreme 3D, Lightwave 3D, Soft Image ...., etc.

In fact, to my own experience the vectorcardiogram is less useful during chronic stages of heart diseases. Its real stage should be Emergency Service, Coronary Care Unit, and Intensive Care Unit. I wish to thank my colleagues in the teaching hospitals in Europe, North America, and Far East for them pressing me for the emergency vectorcardiographic diagnosis.

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